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RESEARCH Open Access
Use of 3D-computed tomography angiography
for planning the surgical removal of pineal region
meningiomas using Poppen’s approach: a report
of ten cases and a literature review
Yunqian Li
1
, Gang Zhao
1
, Honglei Wang
1
, Wanan Zhu
2
, Limei Qu
3
,YeLi
2
and Jinlu Yu
1*
Abstract
Background: There are several treatment approaches for pineal region meningiomas, such as Poppen ’s approach,
Krause’s approach and combinations of the two approaches. We present our experience with the use of 3D-
computed tomography angiography for planning the surgical removal of pineal region meningiomas using a
suboccipital transtentorial approach (Poppen’s approach) and evaluate the role of Poppen’s approach.
Methods: During the perio d from January 2005 to June 2010, ten patients presented to us with pineal region
meningioma. MRI was routinely used to define the tumor size, position, and its relevant complications while 3D-
CTA was applied to define the blood supply of the tumor and the venous complex (VC) shift before operations.
Most of the meningiomas had developed at both sides of the tentorial plane and extended laterally with typical
characteristics of a pineal region tumor.
Results: All tumors were completely removed surgically without any injury to the VC. Postoperative intracranial
infection occurred in one case who recovered after antibiotics were given. Postoperative intraventricular

hemorrhage and pneumocephalus were found in one case, but fully recovered after conservative treatment. In the
nine cases of concurrent hydrocephalus, this was gradually relieved in eight patients and the single case that
became aggravated was successfully treated with ventriculoperitoneal shunt. Moreover, the follow-up MRI
examinations did not indicate any recurrence of the meningiomas.
Conclusion: We found that the use of Poppen’s approach is strongly supported for the successful removal of
pineal region meningiomas without serious complications.
Keywords: Pineal region, meningiomas, 3D-CTA, Poppen?’?s approach
Background
The pineal region contai ns certain tissues that have dis-
tinct histological characteristics, including the pineal
gland and several parapi neal structures such as the pos-
terior third ventricle and the aqueduct, brain, dura and
vessels [ 1]. The list of tumo rs that can arise within the
pineal region is extensive and encompasses germ cell
tumors, pineal parenchymal cell tumors, gliomas and
meningiomas, in which meningiomas are a rare clinical
occurrence, as they only account for about 8% of all
pineal region tumor s [2]. However, treatments f or
meningiomas within the pineal region using microsurgi-
cal manipulation is highly challenging as a result of sev-
eral factors, such as its deep location, complicated
surrounding vascular netwo rks including the deep veins
that drain midline brain structures and supplying
arteries, and the anatomical obstacles of the tentorium
and falx [3].
Recent reports of surgical interventions in the pineal
region for meningiomas are mostly gained from inde-
pendent studies that describe surgical approaches, such
as Poppen’ s approach, Krause’ s approach and
* Correspondence:

1
Department of Neurosurgery, The First Bethune Hospital of Jilin University,
71 Xinmin Avenue, Changchun 130021, China
Full list of author information is available at the end of the article
Li et al. World Journal of Surgical Oncology 2011, 9:64
/>WORLD JOURNAL OF
SURGICAL ONCOLOGY
© 2011 Li et al; licensee BioMed Central Ltd. This is an Open Acce ss article distribut ed under the terms of the Creative Commons
Attribution License ( which perm its unrestricted use, distribution, and reproductio n in
any medium, provided the original work is properly cited.
combinations of the two approaches. It can be very diffi-
cult for clinicians to choose the most appropriate treat-
ment approach [2,4,5]. The ten meningiomas in t his
study were successfully removed surgically using Pop-
pen’s a pproach. Before each surgery, 3D-CTA examina-
tions were performed to assist Poppen’s a pproach. The
findings of this study suggested that preoper ative CTA
can greatly ai d in the understanding of the anatomical
relationship between the deep venous system and the
tumor and its blood supply. Additionally, this study
demonstrates that Pop pen’ s a pproach is clinically feasi-
ble for the treatment of meningiomas within the pineal
region, and it provides a good prognosis for patients.
Materials and methods
Criteria of inclusion
(1). The sites of the meningiomas were restr icted to the
quadrigeminal cistern or the rear of the third ventricle.
(2). The tumor originated in the dura at the origin o f
straight sinus or tentorial free edge and was mainly loca-
lized in the pineal region without severe adhesions. (3).

Cases with tentorial meningiomas that protruded into
the pineal region were excluded from the study [2].
Clinical history
Four male and six fe male patients aged between 40-64
years (average age, 53.3 years) were recruited having suf-
fered symptoms for a period of 3 days to 5 years.
Among these patients, six cas es were found to suffer
from headaches, four cases had papilledema, three cases
had hearing loss, one case exhibited limb hemiparesis,
five cases displayed dizziness, four cases presented with
ataxia and one case had paralysis of upgaze. Among the
ten patients, six ha d a KPS score ≥80, ind icating a satis-
factory quality of life, while four had a KPS score <80
which indicated an unsatisfactory quality of life.
Radiological examination
(1). Magnetic resonance imaging (MRI) w as used for
defining the parameters as follows [6,7]. The size of
meningiomas ranged from 1.8 cm to 5.3 cm (average,
3.45 cm) in diameter and the relationship between the
tentorium cerebelli and tumor was divided into infraten-
torial > supratentorial in three cases (Figure 1), supra-
tentorial > infratentorial in tw o cases, supratentorial =
infratentorial in three cases and infratentorial in two
cases (Figure 2 and Figure 3). Ad ditionally, hydro cepha -
lus was found in a mild form in five cases, moderate in
one case, severe in three patien ts and no hydrocephalus
was present in one case.
(2). Computed tomography angiog raphy (CTA) was
applied to detect tumor staining, venous complex (VC,
which includes the medial occipital vein, basal vein,

internal ce rebral veins and great cerebral vein [8]) shift
and blood supply [9]. The degrees of staining were
severe in four cases, moderate in two cases, mild in
three cases and no staining in o ne case. The VC shifted
downwards in three cases, upwards in one case, laterally
in four cases and no shift was observed in two cases.
The blood supply to the tumor was from the pericallosal
arterial branches in one case, the posterior choroidal
artery branches in two cases, the posterior cerebral
artery branch in two cases, the posterior cerebral and
superior cerebellar artery branches in one case, the dura
of the origin of straight sinus in three cases and was
unspecified in one case.
Surgical procedures
After the induction of general anesthesia, lumbar drai-
nage was performed and the three-way tap was kept in
the closed position. Patients were positioned laterally and
abonewindowwithasizeof approximately 9 × 7 cm
was opened on the side of the tumor to expose the super-
ior sagittal sinus, torcular herophil i and transverse sinus.
After releasing some of the cerebrospinal fluid via the
lumbar puncture drainage, the dura was opened, and the
occipital lobe was lifted obliquely from the junction of
the lower and m edian edges after reaching the angle of
the sagittal sinus and the tentorium cerebelli. T he brid-
ging vein from the occipital lobe into the sagittal sinus
was ligated and transected. Following the tentorium cere-
belli and the cerebral falx leading to the pineal region,
the tentorium cerebelli was transected parallel to the
straight sinus in order to expose the tumor. If necessary,

the cerebral falx was incised to help expose the tumor.
The VC was well protected if found to be associated with
the tumor, or it was found after the removal of the
tumor. A Cavitron ultrasonic surgical aspirator (CUSA)
was used for the intracapsular excision of the tumor,
while protecting the medial occipital vein [10].
Postoperative care
All patients were monitored closely for any complica-
tions and resolution of any hydrocephalus. For patients
with WHO grade II atypical meningiomas, adjuvant
radiotherapy was given after discha rge. Patients with
preoperative hydrocephalus were examined every month
with CT after discharge; t he single case without preo-
perative hydrocephalus was followed-up with monthly
telephone conversations. MRI examination w as per-
formed during the follow-up period to check for any
recurrence of meningiomas.
Statistical methods
Using SPSS 13.0 software, thepreoperativeandpost-
operativeKPSscorewereanalyzedwiththeX
2
test and
P-values < 0.05 were considered to be statistically signif-
icant. The data were shown in table 1.
Li et al. World Journal of Surgical Oncology 2011, 9:64
/>Page 2 of 8
Results
Intraoperative results
Out of the ten cases whose meningiomas were removed,
six cases originated from the pineal region and four

cases originated from the dura of the origin of straight
sinus. In eight cases, the VC was retained clearly after
tumor resection. In one case, the VC was retained but
the basal vein on that side was absent. In another case,
the VC was retained, but the bridging veins of the
superior cerebellar vermis were ligated and transected.
Postoperative results
The pathological findings revealed eight pati ents with
WHOgradeI,andtwohadWHOgradeIImeningio-
mas (patients were given conventional radiotherapy
postoperatively). One patient developed a postoperative
intracranial infection and recovered after antibiotics
were administered. Postoperative intraventricular
hem orrhage and pneumocephalu s occurre d in one case,
but this patient recovered and was discharged after co n-
servative treatment. The remaining eight patients had
no postoperative complications.
Follow-up observations
All patients were followed-up for a period of 6-24
months (average, 14 months). Preoperative concurrent
hydrocephalus in nine patients improved after the opera-
tion, and eight of them remained under review after-
wards. However, there was an aggravation of the
hydrocephalus in one of the nine patients and this patient
was treated with a ventriculoperitoneal shunt. The MRI
scans that were performed in the follow-up period
showed no recurrence of any of the meningiomas. During
follow-up, preoperative symptoms improved to varying
degrees; KPS ≥80 was found in nine patients and KPS
<80 was only found in one case, which was significantly

different compared with the preoperative score (X
2
=2.4,
P < 0.05). The data were shown in table 2.
Figure 1 Case 5: A: Sagittal sections of MRI scans showing a huge meningioma which was contrast enhanced in the pineal region.It
grows below and above the tentorium. B-C: CTA images show moderate tumor (T) staining. The meningioma is supplied by the posterior
branch of the cerebral artery (ellipse). VC shows downward shifting (arrow). D: An image of the opening of the cerebral falx (black arrow) and
tentorium (green arrow) that exposed the tumor (T), in order to carry out the piecemeal excision. E: Postoperative contrast-enhanced sagittal MRI
sections showing the surgical removal of the pineal region meningioma; the artefact of the early postoperative period can be seen. F:
Histopathological section of the tumor showing an endothelial WHO grade I meningioma (HE ×200).
Li et al. World Journal of Surgical Oncology 2011, 9:64
/>Page 3 of 8
Discussion
The meningioma in the pineal region accounts are
uncommon, but because of the benign biological beha-
vior of meningiomas in the pineal region and its good
prognosis, it is still worthy of study in order to define a
standard surgical approach that will benefit patients
[2,11,12]. When a pineal region meningioma grows
bilaterally to the tentorial p lane and extends laterally,
the large variation of the tentorial angle will result in a
complicated anatomical relationship between the tumor,
the tentorium and the falx [13].
Currently, the infraten torial supracereb ellar (Krause’ s)
approach, occipital transtentorial (Poppen’ s) approach
and the combination of both approaches are commonly
used. Krause’s approach is essentially a midline posterior
approach to the pineal region. Its main advantage is that
this approach located underneath the major deep veins,
whichlessensthechanceofsevereneurovascularcom-

promise [3]. However, because of the presence of the
tentorium, which produces restricted visualization at
both the lateral and superior corners, Krause’s approach
provides a narrow operative field, which is a limiting
factor. For pineal region tumors, the alternative was
Poppen’ s approach, which provides an extensive and
clearer view of the entire pineal region from ab ove the
tentorium [14]. Therefore, the choice of surgical
approach depends on the relationship between the
tumor and tentorium. If the tumor is located below the
level of tentorium, Krause’ s approach sho uld be used;
otherwise, Poppen’ s approach is preferred. Moreover, if
the tumor is too large to be removed u sing a single
approach, then the combined approach should be per-
formed [10,15,16].
However, in our department, we usually adopt Pop-
pen’ s approach to divide the tentorium and falx to
achieve adequate space during the operation. If the
tumor was too large to be viewed completely in this
approach, it is still feasible to lower the pressure inside
the meningioma sac and pull the unrevealed part of
tumor into the operative field before proceeding with
Figure 2 Case 8: A-B: Axial and sagittal sections of MRI scans showing an enhancing contrast tumor in the pineal region, below the
tentorium. C: CTA image showing intense tumor staining. The tumor is supplied by the posterior cerebral and superior cerebellar arteries
(arrow). D: Exposure of the tumor (T) after sectioning of the tentorium (green arrow), and cerebral falx (black arrow). E: Histopathological section
of the tumor showing a vascular WHO grade I meningioma (HE, x200). F: Postoperative contrast-enhanced sagittal section of the MRI showing
no residual tumor.
Li et al. World Journal of Surgical Oncology 2011, 9:64
/>Page 4 of 8
the o peration. The current ten cases mentioned in this

report were all treated successfully and efficiently using
this treatment approach.
Except for the falx and tentorium, the surgical
removal of pineal region meningioma is also affected
by the VC of the pineal region [17,18]. Pineal region
meningioma commonly results in a shift of the sur-
rounding structures of the quadrigeminal cistern,
stretches the VC and disrupts the normal anatomical
relationship among these structures, causing surgical
difficulties [19]. Therefore, it is crucial to remove the
tumor without damaging the VC, which makes the
preoperative assessment of the relationship between
the tumor and VC very important. Currently, CTA is a
convenient technique that provides a three-dimen-
sional visual reconstruction of the tumor and its blood
supply. It combines the use of x-ray beams that are
passed through the area of interest from various differ-
ent angles to obtain projection ima ges, which are then
computerized into a three-dimensional image. CTA
clearly shows the relationship between the VC and
tumor and al so protects the VC from damage during
the o peration.
In this study, all ten cases with pineal region menin-
giomas underwent preoperative CTA examination,
which provided data regarding the feeding vessels to the
tumor, tumor staining a nd VC sh ift. These results are
consistent with the surgical findings during the opera-
tion, which demonstrated that CTA is a valuable tool to
analyze tumor blood supply and VC shift preoperatively.
It is a useful technique to detect the fee ding vessels of

the tumor during tumor removal and to reduce both
Intra operative blood loss and operative time. The pineal
region meningiomas can be divided into primary and
secondary meningiomas [2,11,19]. Primary meningiomas
arederivedfromtheconnectivetissueofthepineal
gland or the velum interpositum. It is usually not adher-
ent to the dura [20], whereas the secondary tumors ori-
ginate from the dura of the origin of the straight sinus
or the tentorial free edge and grows into the pineal
region [21]. In this study retrospective analysis of CTA
images of these pineal region meningiomas, combined
Figure 3 Case 10: A-B: Axial and sagit tal sections of MRI scans that show a contrast-enhanced tumor in the pineal region be low the
tentorium compressing the brainstem. C: CTA did not demonstrate tumor staining or a feeding artery. D: Postoperative CT scan showing
hemorrhage in the lateral ventricle and pneumocephalus. E: Histopathological section of the tumor showing a WHO grade II meningioma (HE,
x200). F: Postoperative sagittal MRI section showing no residual tumor.
Li et al. World Journal of Surgical Oncology 2011, 9:64
/>Page 5 of 8
with intraoperative findings, revealed that the extent of
the tumor staining and tumor blood supply was related
to tumor classification. Primary meningiomas h ad a
clear arterial supply, which was mainly from the carotid
arterial system. Therefore, CTA re vealed moderate or
high staining. Secondary meningiomas were found to
have no specific feeding arteries and showed a weak
staining pattern. This may be due to the poor blood
supplythatoriginatesmainlyfromthemeningeal
branches of the external carotid system. In order to
understand the structural relationship between tumor
and o ther vessels fully, surgeons are advised to use 3D
reconstructions preoperatively to avoid being misled by

the radiological reports.
Konovalov has reported 10 cases o f surgical treatment
of pineal region meningiomas. These reported cases
were all s uccessfully treated using Poppen’ sapproach
with the patients placed in a semi-reclining position. In
their cohort, six patients with occlusion of the great
cerebral vein or branches of the VC all had a good
prognosis [2]. In our study, the ten cases had similar
clinical presentations and imaging features. However, in
order to avoid the risk of air embolism, we ado pted the
lateral position for surgical treatment [22]. In addition,
the VC and its tributaries were well-protected intrao-
peratively, and this was supported by the preoperative
CTA examination and the technological advancement of
microsurgical techniques. Moreover, Lozier systemati-
cally reviewed pineal region meningiomas that origi-
natedfromtheveluminterpositum,andusedKrause’ s
approach for treatment, achieving a good prognosis [23].
Ziyal reported a combined approach to provide a wider
exposure of the pineal region with less brain retraction
compared to Poppen’ s or Krause’s approach alone. This
alternative treatment is applicable to certain large and
giant tumors of the pineal area. As demonstrated in
their study, the combined approach was successful in
the removal of large pineal region tumors in six cases,
Table 1 Clinical histories and previous observations are summarized
Case
No.
Sex/
age

Duration Clinical
presentation
KPS CTA Blood supply Size (cm) Position Hydrocephalus
1 Female/
46
years
8
months
Headache,
Papilledema, Hearing
loss
80 Severe
staining, VC
shift upward
Pericallosal arterial
branches
4.7 × 2.1 ×
3.0 (an
average of
3.3)
Infratentorial
>
supratentorial
Moderate
2 Male/61
years
2
months
Headache,
papiledema, limb

hemiparesis
70 Moderate
staining, VC
shift left
Posterior choroidal
artery branches
4×4×3(an
average of
3.7)
Supratentorial
=
infratentorial
Severe
3 Male/42
years
3
months
Headache, dizziness,
papilledema, Ataxia
70 Mild staining,
VC shift left
dura of the origin of
straight sinus
3.0 × 2.5 ×
2.0 (an
average of
2.5)
Infratentorial
>
supratentorial

Severe
4 Female/
64
years
4 years Dizziness, Ataxia 90 Mild staining,
VC shift left
dura of the origin of
straight sinus
4.3 × 4.1 ×
3.3 (an
average of
3.9)
Supratentorial
>
infratentorial
Mild
5 Female/
64
years
5 years Papilledema, memory
loss, ataxia, paralysis
of upgaze
60 Severe
staining, VC
shift
downward
posterior cerebral
artery branch
5.0 × 5.0 ×
4.0 (an

average of
4.7)
Infratentorial
>
supratentorial
Mild
6 Female/
62
years
3 days Headache 90 Mild staining,
VC shift
downward
dura of the origin of
straight sinus
4.6 × 3.9 ×
4.2 (an
average of
4.2)
Supratentorial
>
infratentorial
Mild
7 Male/41
years
2 years Headache 90 Moderate
staining, VC
shift right
posterial choroidal
artery branches
4×3×3(an

average of
3.3)
Supratentorial
=
infratentorial
None
8
Female/
60
years
4 years Dizziness, hearing
loss
80 Severe
staining, VC
Shift
downwards
posterior cerebral
artery branch
4.7 × 5.2 ×
6.0 (an
average of 5.
3)
Supratentorial
=
infratentorial
Mild
9 Female/
53
years
3 years Dizziness, ataxia 80 Severe

staining, VC
unaffected
posterior cerebral and
superior cerebellar
artery branches
2×2×1.5
(an average of
1.8)
Infratentorial Mild
10 Male/40
years
2 years Headache, dizziness,
hearing loss
70 No staining
and VC shift
not specified 2 × 2 × 1.5
(an average of
1.8)
Infratentorial Severe
Li et al. World Journal of Surgical Oncology 2011, 9:64
/>Page 6 of 8
including four tentorial meningiomas, one pineocytoma,
and one epidermoid cyst [4].
We prefer Poppen’s approach as it provides the short-
est distance to reach the tumor and the widest panora-
mic view f or removing the tum or. Although P oppen’ s
approach can easily damage midline structures, such as
the VC and visual cortex, because it stretches the occipi-
tal l obe, this is preventable. Methods of prevention are
as follows: 1) open the cerebral falx and tentorium to

expose the midline and bilateral structures; 2) protect
the VC with the use of CUSA or pushing VC in other
directions than just superiorly; and 3) place a preopera-
tive indwelling lumbar drain to reduce intracranial pres-
sure and r etract the occipital lobe to reduce occipital
visual cortex damage. When there is obs tructive hydro-
cephalus, the most common form of obstruction is not
complete, which means t hat some CSF can be released
intraoperatively. Even when the obstruction is complete,
some CSF can leak through the subarachnoid space.
Sometimes, a small volume of CSF can relieve the
degree of retraction injury to the occipital lobe. Two
cases in our study (cases 9 and 10, respectively), which
were located entirely below the tentorium, fitted the cri-
teria Krause’ s approach according to the relevant
principles of the treatment of pineal region meningioma.
However, we used Poppen’s approach and opened the
tentorium so th at the tumor and its feed ing arteries
were fully exposed, which showed immense
practicability.
In addition to protecting the VC, it is also very impor-
tant to treat any hydrocephalus, which is the key factor
in influencing the prognosis. Pineal region tumors affect
the rear of the third ventricle and cerebral aqueduct,
resulting in obstructive hydrocephalus. Previously, it was
reported that producing a surgical window on the rear
of the third ventricle facilitates the circulation of cere-
brospinal fluid; however, this might lead to more serious
injury [24]. In our case studies, hydrocephalus was
relieved or disappeared in eight of our patients after the

removal of tumors. In one case, hydrocephalus was
aggravated but was successfully treated with a cerebral
shunt.
Conclusion
In summary, for meningiomas in the pineal region, 3D-
CTA is of great clinical value to distinguish the anato-
mical relationship between the tumor, peripheral arteries
and venous complex. This case series strongly supports
Table 2 Surgical treatments and the follow-up record for each patient case are summarized
Intraoperative Postoperative Follow-up
Case
No.
Origin VC Type Complication Other
therapy
Time KPS Hydrocephalus Relapse
1 Pineal region Retained and
clear
Meningioma,
WHO grade I
No No 6
months
90 Mild No
2 Pineal region Retained and
clear
Nontypical
meningioma,
WHO grade II
No Conventional
Radiation
12

months
70 Shunt No
3 Dura of the
origin of straight
sinus
Retained and
clear
Meningioma,
WHO grade I
No No 18
months
90 Mild No
4 Dura of the
origin of straight
sinus
Bridging vein
ligation
Meningioma,
WHO grade I
No No 12
months
100 No No
5 Pineal region Retained and
clear
Meningioma,
WHO grade I
No No 24
months
80 No No
6 Dura of the

origin of the
straight sinus
Retained and
clear
Meningioma,
WHO grade I
Intracranial infection No 12
months
100 No No
7 Pineal region Retained and
basal vein
absent
Meningioma,
WHO grade I
No No 18
months
100 No No
8 Dura of the
origin of the
straight sinus
Retained and
clear
Meningioma,
WHO grade I
No No 12
months
100 No No
9 Pineal region Retained and
clear
Vascular

meningioma,
WHO grade I
No No 12
months
100 No No
10 Pineal region Retained and
clear
Nontypical
meningioma,
WHO grade II
Postoperative intraventricular
hemorrhage and
pneumocephalus
Conventional
Radiation
24
months
90 Mild No
Li et al. World Journal of Surgical Oncology 2011, 9:64
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w.wjso.com/content/9/1/64
Page 7 of 8
the u se of Poppen’ s approach in the surgical treatment
of pineal region meningiomas.
Acknowledgements
The authors thank Medjaden Bioscience Limited for assisting in the
preparation of this paper.
Funding support
This study had no funding support
Author details

1
Department of Neurosurgery, The First Bethune Hospital of Jilin University,
71 Xinmin Avenue, Changchun 130021, China.
2
Department of Radiology,
The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun
130021, China.
3
Department of Pathology, The First Bethune Hospital of Jilin
University, 71 Xinmin Avenue, Changchun 130021, China.
Authors’ contributions
LYQ wrote the initial draft. LYQ, ZG and WHL contributed equally to this
work. YJL is the operator and guarantor. All authors read and approved the
final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 12 March 2011 Accepted: 15 June 2011
Published: 15 June 2011
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doi:10.1186/1477-7819-9-64
Cite this article as: Li et al.: Use of 3D-computed tomography
angiography for planning the surgical removal of pineal region
meningiomas using Poppen’s approach: a report of ten cases and a
literature review. World Journal of Surgical Oncology 2011 9:64.
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